- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.71 / $156.44 / $210.82
| Facility | | $54.71 | $156.44 | $210.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.71 / $54.71 / $54.71
| Professional | | $54.71 | $54.71 | $54.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.71 / $86.36 / $146.03
| Professional | | $54.71 | $86.36 | $146.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.61 / $51.61 / $54.71
| Facility | | $51.61 | $51.61 | $54.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.50 / $46.50 / $54.71
| Professional | | $46.50 | $46.50 | $54.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.79 / $54.71 / $88.67
| Professional | | $49.79 | $54.71 | $88.67 |